Meeting the needs of adolescent parents and their children
Posted: Jun 6 2016
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.
Gillian Thompson; Canadian Paediatric Society, Adolescent Health Committee
Paediatr Child Health 2016;21(5):273.
Adolescent parents and their children present to health care practitioners as two paediatric patients, each with unique health care needs. Young parents and their children may be at risk for negative health outcomes, not directly as a consequence of maternal age but because of poverty and other inequities in the social determinants of health. The health needs of child and mother are best assessed using a nonjudgmental approach, appropriate screening tools and open questions that address both preventative and acute health issues. The dyad’s co-existing needs may be anticipated as they relate to growth and development, infant and adolescent mental health, nutrition and food security, safety, relationships, parenting, education, sexual health and the facilitation of supports and resources. Care providers who understand adolescent development and integrate medical home elements of a patient-centred ‘medical home’ into their practices are ideally positioned to facilitate positive health outcomes for both mother and child.
Key Words: Adolescent mothers; Adolescent parenting; Social determinants of health; Social inequities; Teen pregnancy
Adolescent parenting and implications for health
There are nearly 13,000 infants born to adolescent parents each year in Canada. Overall, Canada experienced a 47% decrease in adolescent births between 1990 and 2010, leveling with a birth rate of 13.5/1000. There are geographical exceptions to the general decline in adolescent birth rates, with some regions showing an increase, notably the Atlantic provinces. The current practice point highlights the unique health needs of adolescent parents (<20 years of age) and their children and recommends some basic strategies to optimize outcomes.
There is substantial literature summarizing the adolescent pregnancy and parenting experience, as well as in-depth research exploring maternal and child outcomes over several decades.- Adolescent mothers have higher rates of mental health disorders,- repeat pregnancy, substance use- and domestic violence, often in the context of lower self-esteem, socio-economic status, income, educational attainment and social support.- The children of adolescents are at increased risk for prenatal death, premature birth and low birth weight. These risks often co-exist or are accentuated among pregnant adolescents who, on average, have higher levels of substance use, smoking and sexually transmitted infections (STIs) along with lower levels of education, income, prenatal care and breastfeeding. The children of adolescent mothers may also experience growth and development issues, particularly cognitive and speech and language delays,- have higher risk for accidental injury and neglect, and encounter challenges with behaviour and in school. Later, as adolescents, they are at higher risk for substance use, early sexual activity and becoming adolescent parents themselves. They are more likely to struggle academically, which further limits their educational opportunities, vocational options and financial security. At the same time, it must be emphasized that many adolescents excel as parents, and that some choose to parent at a young age for personal, cultural or familial reasons. Successful parenting is particularly evident in circumstances that include supportive social networks, a positive parenting environment and limited adversity.
More recent long-term studies have pointed less toward maternal age as a direct cause for negative outcomes than toward the impact of social determinants of health inequities, especially poverty. Many adolescent parents live in poverty and continue to experience its many obstacles. Health care providers who have a thorough appreciation of the social issues at play and are mindful of the developmental challenges facing both children and their adolescent parents are ideally situated to help young families.
Health issues for adolescent parents and their children
Needs of the adolescent mother
Adolescents can be difficult to engage in preventive health care services, in part because they are basically physically healthy, do not anticipate needing a health intervention, are protective of their own privacy or on issues of confidentiality, and fear being judged. Because of early pregnancy or parenting, adolescent mothers are often cared for in a paediatric or family practice setting. It is common for adolescent mothers to have general health maintenance, sexual health and mental health needs, with more specific supports needed to access psychosocial and practical, everyday life resources.
Higher rates of psychosocial problems in the adolescent parenting population, such as interpersonal violence, relationship conflict, abuse and trauma as well as educational, employment and financial challenges are well described in the literature.- Mental health disorders are common, including depression (antenatal and postpartum), post-traumatic stress disorder, anxiety and substance misuse.- The estimated rate for depression in adolescent mothers falls between 16% and 44%; even this wide range is twice the estimated rates for nonpregnant adolescent or adult women.
Prevalent sexual and reproductive health requirements include access to birth control, STI treatment, and preventing or managing repeat pregnancies. The repeat pregnancy rate is as high as 23% within 24 months of a first birth for this age group. Prevention requires seamless access to various birth control methods, including long-acting reversible contraceptives (LARC). As with adult parents, health care providers must consider attachment, lactation and parenting factors as integrated and fundamental to appropriate paediatric care, but they also need to deliver such care in the context of adolescent development.
Helpful adolescent assessments and screens that can be incorporated effectively into an office visit include the HEEADSSS (Home / Education, Employment / Eating /Activities / Drugs / Sexuality/Suicide, Depression/Safety)- or SSHADESS (Strengths / School / Home / Activities / Drugs/substances / Emotions/eating / Depression / Sexuality / Safety screens for obtaining a comprehensive strength-based psychosocial assessment, CRAFFT for investigating substance abuse, and the Beck Depression Inventory or Edinburgh Postnatal Depression Screen for assessing mental health (Table 1). However, while many health and psychosocial risk factors undoubtedly exist before pregnancy, the decision to parent young is often deliberate and it can and commonly does bring new direction to family life, along with motivation to be a good parent, to pursue life goals, and to improve socio-economic circumstances and overall quality of life.
Needs of the child
Although the children of adolescent parents need essentially the same things as children of adult parents, the context of their needs can differ considerably. The importance of providing anticipatory guidance, along with assessments and teaching around growth and development, nutrition, feeding, sleep, safety and immunizations remains paramount. Consideration needs to be given at the same time to factors specific to the child’s young parents, such as the developing adolescent brain, the obtainment of their own adolescent developmental tasks or milestones, the impact of social determinants of health and their (usually limited) access to social supports, because such factors inevitably impact parenting practices.
Potential areas of vulnerability for the children of adolescents include difficulties in speech and language development, less engagement in preventative health maintenance visits and more frequent use of acute care services. Neglect and unintentional injury, disorders of attachment and regulation, and behaviour problems may present as or result in feeding, sleep, growth or nutritional difficulties. Safety of the home environment should be considered, including assessment for maltreatment, exposure to interpersonal violence and the need to involve child protective services. Therefore, care for the children of adolescents should emphasize healthy parent-child interactions, mental health, early intervention and the facilitation of services (Table 2). A developmental screen (eg, the Nipissing District Developmental Screen  or the Ages and Stages Questionnaire (ASQ) and Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)) along with a targeted speech and language screen should be incorporated into the 18-month or regular immunization visits to monitor potentially vulnerable areas and to ensure earlier identification and intervention.
Role of the adolescent father
Most fathers who parent with adolescent mothers are not adolescents themselves but are, on average, five years older than young mothers. Over 80% of fathers do not live with their child, although up to one-half visit on a weekly basis. Their financial contribution to child-rearing is limited because they, too, are often living with poverty, limited education, tenuous employment or (potentially, at least) a criminal history. Domestic violence and relationship problems can jeopardize family safety, and health care providers need to ask about psychosocial stressors and offer information and support in tenuous circumstances.
It should also be noted, however, that paternal involvement has the potential to benefit both maternal and child outcomes. The literature has established that a father’s involvement can have positive impacts on maternal depression, breastfeeding rates, parenting practices and family functioning, as well as a child’s health and well-being, including psychosocial, cognitive and behavioural outcomes. The early engagement of fathers, from the prenatal period onward, is essential to facilitating involvement in children’s lives. It is important for health care providers to actively include fathers in encounters along the continuum of care, whenever possible.
Recommended model of care for adolescent parents and their children
The population of adolescent parents and their parenting experience have been well studied in the United States. The American Academy of Pediatrics supports a ‘medical home’ model of care for adolescent parents: one where care for both parent and child is “accessible, family-centred, developmentally appropriate, continuous, comprehensive, coordinated, compassionate, and culturally sensitive”. Philosophically, this approach is transferable to the Canadian context and has been incorporated into some hospital clinics (eg, The Hospital for Sick Children [Toronto, Ontario]), adolescent parent housing/resource centres and community health centres (eg, the Children’s Hospital of Eastern Ontario/St Mary’s home in Ottawa). Hospital or clinic-based models have proven successful due, in part, to the allocation of specialized interdisciplinary resources in places where mother and child can receive holistic care together. Central to this model’s foundation are the beliefs that social determinants of health for both the adolescent and her child can be addressed in a ‘medical home’ base and that health inequities can be reduced by facilitating interventions such as triaging needs, connecting patients with targeted resources, and using an interdisciplinary team approach to the full spectrum of care needs. The medical home model should incorporate the extended family and each individual’s support system into care of the young family, always considering confidentiality and the adolescent’s autonomy. Creative educational and communication tools are being trialed or used with adolescents, including texting, apps and online tools, and should be incorporated as often as interest, effectiveness and accessibility allows.
Transferring components of care delivery into community practice
While specialized interdisciplinary models are ideal, there are many adolescent parents requiring tailored services who live beyond the reach of specialized urban centres. Certain components of care delivery are still transferable to a community-based practice, ideally when anticipatory guidance and the facilitation of care provide a smooth transition from the prenatal to postnatal period. Health care providers who can successfully promote positive outcomes for an adolescent, her baby and (possibly) her partner and extended family are also those who maintain close and sustained follow-up, have office or clinic staff who are engaging, nonjudgmental and educated in working with adolescents, and who emphasize contraception and family planning as well as encouraging continuing education. The potential advantage of offering these optimal components of care to adolescent-led families is the active mitigation of risk: more and better employment, independence, stronger school engagement, adherence to condom and long-term contraceptive use, fewer repeat pregnancies and higher immunization rates.
Ideally, an enhanced collaborative interdisciplinary network can be created by connecting traditional population health approaches with primary care responsibilities. Meeting patient needs within the community will require outreach and communication with professionals and agencies that can work together to enhance youth-friendly patient care beyond the health care provider’s expertise. This linkage can offer an adolescent-focused approach in any setting, including a community office. Cultural norms and traditions relating to pregnancy, parenting and family structure may need to be assessed and integrated into individual care. Incorporating paediatric guidelines endorsed by the Canadian Paediatric Society such as the Rourke Baby Record or the Greig Health Record into regular office visits where a child’s well-being is understood in the context of family and community can provide a framework for optimal evidence-based care for both child and parent.
The use of developmental screens can be enhanced with screening for food security and housing, employment, child care, and education needs. The health care provider must have a thorough working knowledge of community-based resources and supportive services, such as food banks, housing services, education, legal and job centres, child development and parenting centres, sexual health clinics, public health programs and, where available, resources specific to adolescent parents. In addition to enhancing child development, local programs may target infant mental health, reading skills, positive discipline and quality preschool learning (Tables 1,2).-
Consider educational and community resource information in waiting or exam rooms that addresses child and adolescent health issues, such as positive parenting, early literacy, speech and language, sexuality and healthy relationships. These materials should be written in clear, simple language and available in multiple languages, where appropriate. Consider referring vulnerable or isolated adolescents to outreach services such as home-based interventions, youth outreach or public health services. For example, a public health nurse is an ideal professional to connect with young parents in their home setting to further assess and link with pertinent resources within the family’s community.
Meeting an adolescent mother’s basic health needs
|Needs||Suggested screening tools, questions and resources|
Growth and development
|Acute illness management|
“Do you have the medications and equipment that you need in order to feel well?”
“Do you have the funds or insurance coverage to be able to pay for this treatment?”
|Sexual health||“Do you have any sexual health needs? I can help with this care or I can tell you about local sexual health clinics. What would you prefer?”|
|Additional mental health screens|
“Do you feel safe in your relationships with your partner and family members?”
“Have you been physically hurt, threatened, afraid or forced sexually in any way in the last six months?”“Have you had any involvement with child protection services?”
“Do you have the supports and resources you need to parent in the ways that you would like?”
“Do you have any concerns about having enough money to pay your bills or to buy what you need for you and your child?”
|Housing||“Do you have any concerns about where you live? About being able to pay rent or becoming homeless?”|
|Education||“Do you have access to a school that helps you pursue your own educational goals?”|
|Employment||“Do you need help with securing employment or pursuing your career goals?”|
|Child care||“Do you have child care arrangements that are safe, affordable and reliable, and that allow you to attend work or school appointments?”|
|Legal||“Do you have any concerns about immigration or custody and access or other legal issues that may require the advice of a lawyer?”|
|Adapted from references -.|
Meeting the basic health needs of children of adolescent mothers
|Needs: Standard paediatric care with areas of emphasis||Suggested screening tools, questions and resources|
|Infant mental health|
There should be youth-centred nonjudgmental staff and a welcoming atmosphere in the office setting with, preferably, some allowance made for the occasional late or missed appointment. Such lapses may be better understood in this age group, who are also contending with conflicting demands, immature executive function, limited resources and high requirements for care. Access to supports and information is hugely important to adolescent parents, who are often inhibited by fears of judgment or stigmatization. Your practice’s readiness to make reminder calls, waive administrative fees for photocopying or completing medical forms, and to provide advocacy letters or donated items are just a few practical ways to engage an adolescent who is learning basic life skills at the same time as parenting, often in difficult social and financial circumstances. Sustaining a long-term positive relationship and encouraging autonomous decision-making, along with reassurance as needed, can contribute to resiliency and positive health outcomes for young families.
This practice point was reviewed by the Community Paediatrics and Fetus and Newborn Committees of the Canadian Paediatric Society. The author also wishes to thank Dr. Megan Harrison, with the Children’s Hospital of Eastern Ontario, Dr. Miriam Kaufman and Dr Katherine Hick, as well as Sharon Lorber and Nicole Murphy in the Young Families Program (Division of Adolescent Medicine) at The Hospital for Sick Children, for their time and expertise.
CPS ADOLESCENT HEALTH COMMITTEE
Members: Giuseppina Di Meglio MD, Johanne Harvey MD (past member), Natasha Johnson MD, Margo Lane MD (Chair), Karen Leis MD (Board Representative), Mark Norris MD, Gillian Thompson NP-Paediatrics
Liaison: Christina Grant MD, CPS Adolescent Health Section
Principal author: Gillian Thompson RN(EC),BScN,MN,NP-Paediatrics
- Statistics Canada. Live births, by age of mother, Canada, provinces and territories, annual, CANSIM table 102-4503, 2011: www5.statcan.gc.ca/cansim/a26?lang=eng&id=1024503 (Accessed April 5, 2016).
- McKay A. Trends in Canadian national and provincial/territorial teen pregnancy rates: 2001-2010. Canadian Journal of Human Sexuality 2013;21(3/4):161-75: http://www.sieccan.org/pdf/TeenPregancy.pdf (Accessed April 5, 2016).
- Pinzon JL, Jones VF, Committee on Adolescence, Committee on Early Childhood. Care of adolescent parents and their children. Pediatrics 2012;130(6):e1743-56.
- Ruedinger E, Cox JE. Adolescent childbearing: Consequences and interventions. Curr Opin Pediatr 2012;24(4):446-52.
- Black AY, Fleming NA, Rome ES. Pregnancy in adolescents. Adolesc Med State Art Rev 2012;23(1):123-38.
- Klein JD, American Academy of Pediatrics Committee on Adolescence. Adolescent pregnancy: Current trends and issues. Pediatrics 2005;116(1):281-6.
- Hodgkinson S, Beers L, Southammakosane C, Lewin A. Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics 2014;133(1):114-22.
- Harrison ME, Weinstangel H, Dalziel N, Moreau KA. A collaborative outreach clinic for pregnant youth and adolescent mothers: Description of a pilot clinic and its patients. Paediatr Child Health 2014;19(5):247-50.
- Brown JD, Harris SK, Woods ER, Buman MP, Cox JE. Longitudinal study of depressive symptoms and social support in adolescent mothers. Matern Child Health J 2012;16(4):894-901
- Reid V, Meadows-Oliver M. Postpartum depression in adolescent mothers: An integrative review of the literature. J Pediatr Health Care 2007;21(5):289-98.
- Thompson G, Madigan S, Wentzel K, Dineley B, Lorber S, Shouldice M. Demographic characteristics and needs of the Canadian urban adolescent mother and her child. Paediatr Child Health 2015;20(2):72-6.
- Barnet B, Rapp T, DeVoe M, Mullins CD. Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: A rebirth of economic and policy considerations. Arch Pediatr Adolesc Med 2010;164(4):370-6.
- Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Schootman M, Cottler LB, Bierut LJ. Associations between multiple pregnancies and health risk behaviors among U.S. adolescents. J Adolesc Health 2010;47(6):600-3.
- Shaw M, Lawlor DA, Najman JM. Teenage children of teenage mothers: Psychological, behavioural and health outcomes from an Australian prospective longitudinal study. Soc Sci Med 2006;62(10):2526-39.
- Sue Newman B, Campbell C. Intimate partner violence among pregnant and parenting Latina adolescents. J Interpers Violence 2011;26(13):2635-57
- Lipman EL, Georgiades K, Boyle MH. Young adult outcomes of children born to teen mothers: Effects of being born during their teen or later years. J Am Acad Child Adolesc Psychiatry 2011;50(3):232-41, 5e4.
- Fleming N, Ng N, Osborne C, et al. Adolescent pregnancy outcomes in the province of Ontario: A cohort study. J Obstet Gynaecol Can 2013;35(3):234-45.
- Oxford M, Spieker S. Preschool language development among children of adolescent mothers. J Appl Dev Psychol 2006;27(2):165-82.
- Morinis J, Carson C, Quigley MA. Effect of teenage motherhood on cognitive outcomes in children: A population-based cohort study. Arch Dis Child 2013;98(12):959-64.
- Rafferty Y, Griffin KW, Lodise M. Adolescent motherhood and developmental outcomes of children in early head start: The influence of maternal parenting behaviors, well-being, and risk factors within the family setting. Am J Orthopsychiatry 2011;81(2):228-45.
- Gueorguieva RV, Carter RL, Ariet M, Roth J, Mahan CS, Resnick MB. Effect of teenage pregnancy on educational disabilities in kindergarten. Am J Epidemiol 2001;154(3):212-20.
- Kahn JR, Anderson KE. Intergenerational patterns of teenage fertility. Demography 1992;29(1):39-57.
- Stiles AS. Case study of an intervention to enhance maternal sensitivity in adolescent mothers. J Obstetric Gynecol Neonatal Nurs 2010;39(6):723-33.
- SmithBattle L, Leonard V. Inequities compounded: Explaining variations in the transition to adulthood for teen mothers’ offspring. J Fam Nurs 2012;18(3):409-31.
- Patel PH, Sen B. Teen motherhood and long-term health consequences. Matern Child Health J 2012;16(5):1063-71.
- Al-Sahab B, Heifetz M, Tamim H, Bohr Y, Connolly J. Prevalence and characteristics of teen motherhood in Canada. Matern Child Health J 2012;16(1):228-34.
- Kingston D, Heaman M, Fell D, Chalmers B; Maternity Experiences Study Group of the Canadian Perinatal Surveillance System, Public Health Agency of Canada. Comparison of adolescent, young adult, and adult women’s maternity experiences and practices. Pediatrics 2012;129(5):e1228-37.
- Harden A, Brunton G, Fletcher A, Oakley A. Teenage pregnancy and social disadvantage: Systematic review integrating controlled trials and qualitative studies. BMJ 2009;339:b4254.
- Fleming N, O’Driscoll T, Becker G, et al. Adolescent pregnancy guidelines. J Obstet Gynaecol Can 2015;37(8):740-59.
- Barnet B, Liu J, DeVoe M, Duggan AK, Gold MA, Pecukonis E. Motivational intervention to reduce rapid subsequent births to adolescent mothers: A community-based randomized trial. Ann Fam Med 2009;7(5):436-45.
- Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5(7):75-90.
- Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. Contemp Pediatr 2004;21(1):64-90.
- Ginsburg K. Viewing our adolescent patients through a positive lens. Contemp Pediatr 2007;24(1):65-76.
- Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156(6):607-14.
- Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess 1996;67(3):588-97.
- Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
- Giedd JN. The teen brain: Insights from neuroimaging. J Adolesc Health. 2008;42(4):335-43.
- Robb Y, McInery D, Hollins-Martin C. Exploration of the experiences of young mothers seeking and accessing health services. J Reprod Infant Psychol 2013;31(4):399-412.
- Pittard WB 3rd, Laditka JN, Laditka SB. Associations between maternal age and infant health outcomes among Medicaid-insured infants in South Carolina: Mediating effects of socioeconomic factors. Pediatrics 2008;122(1):e100-6.
- Flaherty SC, Sadler LS. A review of attachment theory in the context of adolescent parenting. J Pediatr Health Care 2011;25(2):114-21.
- Black MM, Papas MA, Hussey JM, Dubowitz H, Kotch JB, Starr RH Jr. Behavior problems among preschool children born to adolescent mothers: Effects of maternal depression and perceptions of partner relationships. J Clin Child Adolesc Psychol 2002;31(1):16-26.
- Dahinten SV, Ford L. Validation of the Nipissing District Developmental Screen for use with children and toddlers: Working paper. Vancouver, B.C.: Consortium for Health, Intervention, Learning and Development, 2004.
- Squires J. ASQ-3 user’s guide. Baltimore, MD: Paul H. Brookes Publishing, 2009:xxiv,227.
- Squires J, Bricker DD, Twombly E, Squires J. Ages and stages questionnaires, social-emotional (ASQ:SE): A parent-completed, child-monitoring system for social-emotional behaviors. Baltimore, MD: Paul.H. Brookes Publishing, 2002: vol. 1.
- Hollman D, Alderman E. Fatherhood in adolescence. Pediatr Rev 2008;29(10):364-6.
- Leslie K, Dibden L. Adolescent parents and their children: The paediatrician’s role. Paediatr Child Health 2004;9(8):561-4.
- Baer TE, Gottlieb L, Sandel M. Addressing social determinants of health in the adolescent medical home. Curr Opin Pediatr. 2013;25(4):447-53.
- Klerman LV. Adolescent pregnancy in the United States. Int J Adolesc Med Health 2002;14(2):91-6.
- Cox JE, Buman MP, Woods ER, Famakinwa O, Harris SK. Evaluation of raising adolescent families together program: A medical home for adolescent mothers and their children. Am J Public Health 2012;102(10):1879-85.
- Ford-Jones EL, Williams R, Bertrand J. Social paediatrics and early child development: Part 1. Paediatr Child Health 2008;13(9):755-8.
- Leduc D, Rourke L, Rourke J. The Rourke Baby Record: www.rourkebabyrecord.ca
- Greig AA, Constantin E, LeBlanc CMA, Riverin B, Tak-Sam Li P, Cummings C. An update to the Greig Health Record - Executive summary. Paediatr Child Health 2016;21(5):265-68.
- Garg A, Jack B, Zuckerman B. Addressing the social determinants of health within the patient-centered medical home: Lessons from pediatrics. JAMA 2013;309(19):2001-2.
- Bertrand J, Williams R, Ford-Jones L. Social paediatrics and early child development - the practical enhancements: Part 2. Paediatr Child Health 2008;13(10):857-61.
- Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282(18):1737-44.
- Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry 1999;38(10):1230-6.
- Steinberg AM, Brymer MJ, Decker KB, Pynoos RS. The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psychiatry Rep 2004;6(2):96-100.
- Cohen JA, Kelleher KJ, Mannarino AP. Identifying, treating, and referring traumatized children: The role of pediatric providers. Arch Pediatr Adolesc Med 2008;162(5):447-52.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.